ECE2015 Guided Posters Steroids (9 abstracts)
Using a morning cortisol to predict adrenal reserve and guide management
Conor Woods 1 , Nicola Argese 3 , Matthew Chapman 2 , Rachel Webster 4 , Andrew Toogood 2 , Wiebke Arlt 2 , Paul Stewart 5 , Rachel Crowley 2 & Jeremy Tomlinson 1
1Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, UK; 2Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK; 3Department of Endocrinology, St Andrea Hospital, Rome, Italy; 4Department of Biochemistry, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK; 5Department of Endocrinology, University of Leeds, Leeds, UK.
Background: The short Synacthen test (SST) is the most widely used dynamic assessment of adrenal reserve. In some situations, the SST may be difficult to perform. Random basal cortisol levels could provide an alternative screening assessment to rationalize which patients need dynamic testing. This is highly clinically relevant, given the large numbers of patients taking prescribed glucocorticoids who are at risk of iatrogenic adrenal suppression.
Methods: 3603 SST results (all performed in the morning) were analysed from electronic records in a large secondary/tertiary centre across all specialities. A 30 min cortisol value >549 nmol/l was defined as a pass. Results were divided into sub-groups including age, sex, pituitary, and adrenal pathology and patients taking inhaled corticosteroids (ICS). Receiver operator characteristic curves were used to generate area under the curve (AUC), best-fit cortisol values and to predict cut-off values for specificities and sensitivities.
Results: Baseline and 30 min cortisol levels correlate positively (r=+0.74, P<0.0001). Basal cortisol levels >440 and ≥506 nmol/l gave 99 and 100% specificity respectively for passing the SST. Baseline cortisol <107 nmol/L gave a 99% sensitivity for failing. Cut-off values and AUCs were similar between groups divided by sex, age, and menopausal status. In patients currently taking ICS, 31% failed an SST (71/226). Patients taking ICS with a basal cortisol ≥359 nmol/l (36%, n=81) passed, and those with a cortisol <34 nmol/l (4%, n=9) failed an SST. In post-pituitary surgery patients (n=329), those with basal cortisol above 350 nmol/l (23%) passed, and those below 46 nmol/l (11%) failed the SST.
Conclusion: Baseline cortisol levels can be informative in predicting the SST response. A high clinical index of suspicion of adrenal insufficiency mandates dynamic assessment of adrenal reserve by SST. However, a basal cortisol may have a clinical utility in discrete patient cohorts, such as those on ICS, in whom, within our cohort, 40% (n=90) of SSTs could have been avoided.
Disclosure: This work has been supported by the Medical Research Council (Senior Clinical Fellowship ref. G0802765, J Tomlinson).
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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